CPCA wrote a letter to Jim Macrae, Associate Administrator of Bureau of Primary Health Care, to voice the concerns of health centers regarding apparent modifications to the scope of project change process involving specialty care services.
Recommendations to the BPHC
As with health centers across the country, California’s FQHCs strive to be responsive to the many and diverse needs of the community. Waiting until a patient’s condition becomes an emergency in order to be able to access necessary specialty care, is a failure in the health care delivery system. In developing the PINs on scope of project change requests and specialty care, the BPHC must ensure that this currently too common situation is not exacerbated.
- Support Approved Scope Changes
We strongly urge that the BPHC make any new policy effective from the date of issue and not re-evaluate approved scope changes already in place, which could reduce health center revenues through loss of favorable FQHC reimbursement rates and increase patient costs for needed services which they cannot afford.
California uninsured rates exceed those of the rest of the nation and the uninsured traditionally have more limited access to specialty care. In California, 24.4% of non-elderly adults are uninsured, compared with 18.3% nationwide. Children in California are more likely to be uninsured (20.8%) than in the rest of the country (15.5%). Compared with the rest of the nation, fewer California employers offer health insurance and a higher percentage live in poverty. These are the individuals that will be most impacted by greater limitations on access to specialty care services.
The BPHC has already evaluated the need for the scope change and, through its approval, has created an expectation among the community that they will be able to access this care in their FQHC medical home. For the uninsured who are able to access in-house specialty care services through their FQHC medical home in an approved scope change, an adverse re-evaluation of their scope of project would significantly increase the chances of these patients needing to wait until their condition becomes an emergency before being able to access necessary specialty care services. The BPHC should not contribute to the creation of this adverse result.
- The Services are Needed to Address Patient and Community Needs
One of the many strengths of health centers lies in the community governance structure. A majority of any health center’s Board are patients with intimate knowledge of needed services and a vested interest in providing high-quality, sustainable health care. When a health center requests incorporation of a specialty care service in a scope change, this request should reflect a decision of the health center’s community-based Board. Community flexibility and responsiveness is a hallmark of the FQHC program and should continue in the development of the PINs.
This criterion would be met by providing Board discussion including the factors contributing to the decision on the community need for the particular service.
- The Provision of these Services Would Not Compromise the Provision of Required Services
Specialty care services are necessary for the adequate support of the primary health services. FQHCs are required to provide primary and preventive care services and to ensure their patients have access to additional services either directly or through a referral system. Lack of access to specialists impacts the ability of a health center to adequately provide required primary and preventive care. For example, a patient with diabetes potentially leading to kidney failure needs to be seen by a nephrologist in order to ensure appropriate medication levels, which the FQHC’s primary care physician will then monitor. The medication doses are dependent on an accurate assessment of kidney functions. Without this intervention, primary care is compromised. An FQHC patient with back pain and an abnormal radiology study needs to be seen by a neurologist in order to rule out serious conditions. Primary care physicians can manage most back pain; however, primary care is jeopardized if more serious conditions are a possibility.
Evaluation of this criterion would best be met by demonstrating that the specialty care service is being added for the purpose of supporting the provision of primary care services. The specialty care service is logical and necessary in the continuum of care from primary care services provided by the health center. For example, health centers with documentation verifying a large numbers of diabetic patients may see as necessary, the services of an endocrinologist.
- The Health Center’s Service Population Faces Obstacles in Accessing the Service
As the Mathematica report demonstrates FQHC patients often face month long waits in order to secure necessary specialty care services. Other patients must travel unreasonable distances in order to access these services. Health center patients also face linguistic barriers. The majority of California’s clinic patients are Hispanic (52%) and almost half are limited English proficient. The Mathematica report found most FQHC adult patients face barriers in accessing necessary specialty care services, and specifically found that patients in service areas consisting of at least 40% Hispanics face even greater barriers. As part of the PINs, the BPHC needs to reflect on the ability for FQHC patients to access necessary specialty care services if these services are not made available at the FQHC.
This criterion can be evidenced by documentation of extensive waiting periods for the specific service, the distance to the nearest specialist, and the linguistic capacity of specialists within the service area.
CPCA would also support criteria that consider whether the BPHC is being asked for additional 330 funding and whether the physicians employed or contracted are adequately licensed, credentialed and privileged to provide the care.
|
